UCare Medicare Group Plans - Allina Executive Plan 2023 Formulary (List of Covered Drugs)
Download the complete Formulary or search the list of covered drugs below.
Group Medicare Formulary (List of Covered Drugs) (PDF) Updated 12/1/2023
Group Medicare Formulary (List of Covered Drugs) - Spanish (PDF) Updated 12/13/2023
Prior Authorization Criteria (PDF) Updated 12/1/2023
Step Therapy Criteria (PDF) Updated 3/1/2023
UCare Formulary Exception Criteria (PDF) Updated 10/1/2022
Formulary Change Notice (PDF) Updated 8/1/2023
Part B Medical Injectable Drug Authorization List (PDF) Updated 11/28/2023
| Tier | 30 day supply cost share | 90 day supply cost share |
| Tier 1 Generic drugs |
$10 copay | Available for two copays through mail order or a preferred network pharmacy |
| Tier 2 Preferred brand-name drugs |
$30 copay | Available for two copays through mail order or a preferred network pharmacy |
| Tier 3 Non-preferred drugs |
$30 copay | Available for two copays through mail order or a preferred network pharmacy |
| Tier 4 Specialty drugs |
$30 copay | Available for two copays through mail order or a preferred network pharmacy |
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call Customer Service for more information.
Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.